CMS-10611.MOON 30 day Public Comments Log

**Note: Number cells are color coded to indicate duplicate comments. However, they may not necessarily be in the same order in the written comment.
No.	Organization / Name	Topic	Comment Summary	Link to Comment	Response
1	Penn Presbyterian Medical Center -- Feba Varghese	implementation; burden; delivery timeframe	CMS should only require MOON for benes spending 8+ hrs in observation. Tracking hours for MOON issuance purposes is burdensome to hospitals. The implication of outpatient care applies to all patients spending 8-24 hrs in observation....	Penn Presbyterian	6, 9, 22
2	Noridian MAC Jurisdictions E and F -- Elizabeth Barton	implementation; issuance; free text field; delivery timeframe; bene signature	Multiple inquiries, e.g.: Must hospitals document failure to deliver MOON? Who is liable in failed delivery? Who can deliver MOON -- staff? What if a bene refuses to sign? Is MOON part of medical record? Concerns re: staff ability to fill-in reason for outpatient observation; Who is responsible for educating/responding to providers (MACs vs. QIOs)...?	Noridian	1, 18, 19
3	SCL Health -- Joanne Davidson	free text field; notice content; notification requirements; implementation; delivery timeframe	SCL recommends: 1.) Removal of free text field; other CMS notices lack free text field. If rationale is required, CMS should opt for a standardized statement. 2.) SCL wants a 1-page notice (remove free text + "additional info" fields). 3.) Hospitals should adopt standardized approach to notice delivery -- provide MOON at initiation (MD order) of obs + at registration. 4.) CMS MOON approach is inconsistent with Agency's position re other bene notices -- eg, CMS encourages delivery of ABN before it is clear that the beneficiary will incur financial liability.	SCL Health	6, 9, 11
4	Partners HealthCare System, Inc. -- Keely Macmillan	free text field; notice content; implementation	Partners urges CMS to reduce paperwork by combining the MOON + IM -- thereby eliminating need to deliver both the MOON and the IM to patients receiving 24+ hours of obsv care (MOON), who are eventually admitted as inpatients, triggering IM requirement.	Partners HealthCare System	6
5	University of Kansas Hospital -- Mary Harless	MA concerns; notice content; burden	Concern about: 1.) inclusion of MA enrollees (due to varying MA policies - 2-midnight, CC44 & 3-day qualifying stay + retro, post discharge inpatient downgrade). 2.) Understated provider burden (30-minute vs. 15-minute estimate). 3.) understandability of the form - request for edits to improve clarity (e.g., note)....	University of Kansas	6, 7, 11, 21
6	MetroHealth System -- Tracy Carter	burden; free text field; LEP concerns; retention policies; automated system; bene signature	MHS supports American's Essential Hospital's comments regarding MOON + adds recommendations re strategies to make MOON more understandable to diverse patients, particularly those with lower-literacy and/or LEP capabilities. We also request the agency reconsider strategies to streamline implementation, retention + reporting requirements for providers. In sum, MHS recommends CMS: 1.) Administer the MOON in a manner ensuring comprehension by all (esp. LEP) benes. 2.) Recognize CMS' burden est. is insufficient. MHS estimates implementation as more involved + complex from a care delivery perspective. In sum: MHS requests CMS : (a) Adopt the original MOON (ie, no free text field). (b) Create MOON retention requirements to promote provider efficiency within a limited resource environment: OMB please provide alternate approaches to simplify the process? (c) Incorporate ability to note when a beneficiary refuses to sign -- e.g., include a section for notation of refusal to sign (located in the area specified for bene sig), and (d) Automate MOON to promote system efficiency and accountability and beneficiary engagement.	MetroHealth System	1, 14, 21, 24
7	Society of Hospital Medicine -- Joshua Lapps	notice content; free text field; bene signature; staff signature	SHM has concerns with: 1.) vagueness of free text field leading to inconsistency in obsv. rationale; 2.) required clinical information could necessitate certain provider -- potential physician -- involvement w/MOON completion; 3.) Free text Rationale: CMS should create checkboxes or a standardized rationale for obsv. services (eg, fewer than 2 midnights = obsv). 4.) Bene Signature Refusal: SHM has ethical concerns re: CMS requiring the provider (who is not financially responsible for the patient) to sign the form upon bene refusal to sign. Also, SHM recommends CMS add language to MOON instructions re signature requirement for clarity re provider role in this signature requirement.	Society of Hospital Medicine	1, 2, 3, 4, 26
8	UCSF Medical Center -- Misti Meador	free text field; implementation; issuance; bene signature	UCSF Questions: 1.) Clarify how to address a situation when a patient cannot sign the MOON form & no surrogate identified? 2.) Free text field will place undue burden upon hospitals--will require a clinician issue every MOON. Typically, hospitals have registry staff deliver Observation notices upon admission to an Outpatient status. Under proposal, hospitals will not be able to easily operationalize the issuance of this notice. 3.) If a patient switches from Obsv. to Inpatient and back to Obsv. -- do hospitals have to re-issue MOON?	UCSF Medical Center	2, 22
9	Mayo Clinic -- Robert Howey	free text field; delivery timeframe	Adding the MOON free-text section is problematic and should be removed. Delivery of the MOON should rely on hospital personnel judgment. Whether the MOON is delivered in the first hour or the twenty-sixth hour of observation, the reason for observation remains the same.	Mayo Clinic	9
10	Federation of American Hospitals -- Steve Speil	free text field; content; oral notice; staff signature	FAH comments CMS for successfully addressing many concerns raised re: the MOON since its 1st publication. Further revisions are necessary: 1.) Free Text Field - a.) Will Lead to inconsistencies, is unnecessary and will cause bene confusion. b.) FAH believes the NOTICE Act does not require a free text field. c.) Free text field precludes certain hospital personnel from MOON completion. d.) Removing free text field is consistent w/other CMS notices (IM). e.) If free text field is maintained, FAH provides standardized rationale language to incorporate. 2.) Oral Notice: a.) Guidance - FAH urges CMS to issue oral notification guidance immediately, or postpone MOON oral notification requirements to allow providers an opportunity to operationalize this requirement. b.) FAH urges CMS to add a signature line to the MOON for hospital staff to document a patient’s refusal 2 sign. 3.) Content - Revisit one-page MOON. Reorganizing / reordering / shortening MOON length will improve bene comprehension & clarity. Remove "Additional Information" section; well-vetted ABN is only one page. 4.) MOON, at top of the 1st page, should state applicability to particular Medicare beneficiaries, including MA enrollees + that the MOON applies to MSP scenario. Also, at top of form, MOON should clearly communicate why benes are receiving it...before getting into coverage, etc..	Federation of American Hospitals	1, 3, 11, 25
11	New York StateWide Senior Action Council, Inc. -- Marcus Harazin	three day SNF requirement; implementation; free text field; content; QIOs	NYS supports quick MOON implementation. Revised MOON easier to understand. NYS supports free text field. Suggested MOON edits: CMS should modify MOON to clarify days spent in obsv. will not count toward your 3 day minimum inpatient stay requirement/SNF coverage. NYS also suggests MOON include a statement clarifying Post hospital rehabilitative care will be covered by Medicare Part A if it can be provided in one's home by a Certified Home Health Agency if doctor deems it medically necessary.... Also, add a reminder to MOON that benes may contact their QIO w/a concern about quality of care, status of their admission, or for discharge disagreements. Last, CMS should amend QIO scope of work to require QIOs to counsel persons who disagree with observation services.	New York StateWide	11, 25
12	Center for Medicare Advocacy -- Toby Edelman	three day SNF requirement; delivery/recipients; understandability; appeal rights	CMA applauds: MOON's considerable improvement over earlier version. MOON is: well organized, shorter, crisper, easier to read than previous version, leaves a space blank for the hospital to explain the specific reasons that the patient is classified as an outpatient. CMA's 3 primary concerns with MOON: 1.) Congress intended hospitals to notify all patients, whether receiving Observation or other “outpatient” services, of their “outpatient” status via MOON. 2.) Person who receives the MOON must understand its contents; MOON should go 2 patient + rep. Providing notice only to a patient who cannot understand its significance is defective, not acceptable notice. 3.) CMS has the authority to, and should, allow “outpatients” to appeal their “outpatient” status.	CMA	5, 6, 11
13	BJC HealthCare -- Steven Bernstetter	reading level; free text field; bene signature	Simplify language to a grade or middle school reading level. Clearly define key terms and their relationships to each other as concerns coverage of and payment for services received in the hospital, and organize the rest of the form around these definitions and their implications. Minimize the amount of work required of hospitals to complete the form, including the elimination of any "free text" boxes and their replacement with checklists or other uniform and preformatted language. Enable hospitals to comply with the requirements for both the verbal explanation and physical distribution of the form to the patient via a single signature line. (commenter included attachments of alternative versions of the MOON)	BJC HealthCare	11, 26
14	Michigan Health & Hospital Association -- Vickie Kunz	free text field; notice content; burden; bene signature	Remove the free text field and replace with standard language developed by CMS. Add space at the top of each page for label. The section that describes how observation services affect coverage should be made clearer. The current instructions do not explain refusals or inability to sign. The burden is underestimated and an additional 15 minutes should be added for delivery. . Keeping the free text field increases the logistical burden.	Michigan Health & Hospital	1, 2, 11, 21, 26
15	Premier Inc. -- Corrine Colgan	free text field; issuance; burden; languages; enforcement	A uniform, standardized statement on the reason the patient is an outpatient is preferable. The free text section substantially increases the time and resources hospital staff must dedicate to provide this information. The burden assessment is based on a RN being the hospital staff delivering the notice. We recommend that the agency clarify that other appropriate personnel, as determined by the provider, can also deliver the notice. CMS has substantially underestimated the burden on hospitals of the proposed new requirements for implementing the NOTICE Act. CMS should provide translated forms of the MOON in at least the top 15 non-English languages nationally. A short period of non-enforcement is important to allow providers to get experience delivering the notice. encourage CMS to provide additional guidance and clarification to state survey agencies on appropriate oversight activities of hospital compliance with the NOTICE Act requirements.	Premier Inc.	16, 18, 19, 21
16	Henry Ford Health System -- Matthew Wolocko	free text field; issuance; burden	The reasoning for outpatient services on the MOON should be limited to more general clinical reasons - per initial MOON draft, or approved standardized language provided by CMS or local staff physicians. Further clarification is needed on which staff is expected to deliver the MOON. The estimated cost and burden of providing the MOON did not adequately consider patients with Medicare as a secondary payer. It will be more cumbersome and costly to our hospitals to identify these patients and provide the Notice.	Henry Ford Health System	19, 21
17	FHN -- Colleen Stukenberg	free text field; issuance; notice content	Who will be completing the free text field of the form? Physician, Nurse, Social Services, Case Manager, Registration / Clerical Staff? What is "not an inpatient" based on? (see comment for additional clarification) The cost of delivering the MOON is noted to be 15 minutes by a registered nurse. Is this within the scope of an RN and is this the best use of resources. It seems to be out of the scope to inform patients of their status when the payers cannot come to an agreement on why a patient does not meet inpatient criteria.	FHN	19
18	Harris Health System -- Carolynn Jones	free text field	Consider removing the free text field and replace with check boxes with common reasons for a patient's observation status, or suggested narratives for insertion acceptable to CMS.	Harris Health System	26
19	American College of Emergency Physicians -- Barbara Tomar	burden; delivery timeframe	CMS should make clear what the timeframe is for the est. for # of notices (e.g. 1.4 million per year?). Notices given at time of admission to observation will undoubtedly generate unnecessary confusion on the part of beneficiaries who have been led to believe by the media and certain advocacy groups that any observation services mean huge bills for them and some may leave against medical advice.	American College of Emergency Physicians
20	Palomar Health -- Elly Garner	free text field; implementation; notice content; staff signature; languages	Without revisions the MOON does not meet OMB criteria for approval. Remove the free text field and replace with the previous bullet points in the last version of the MOON. Delay implementation and enforcement. Create additional check boxes to indicate oral notification and when an interpreter is used. Create a signature line for staff when the patient is unable to sign and no representative was available. Provide in additional languages. Change the patient name and id number to be consistent with the IM. Provide additional guidance on implementation of the MOON.	Palomar Health	2, 11, 16, 17
21	American Health Care Association -- Dana Halvorson	appeal rights; three day SNF requirement	Urge CMS to establish a way for beneficiaries placed on observation to argue that such placement is inappropriate given their medical records. CMS has authority under existing law to count all time spent by a patient in the hospital for purposes of qualifying for Part A coverage in a SNF. CMS policy created observation status and CMS action could adjust or rescind it.	AHCA	5
22	JPS Health Network -- Gerry Knowles	DRG adjustment; bene signature	We do not understand the usefulness of the information collection to CMS. Recommend a small adjustment in the DRGs to reflect the increased cost for this requirement. Recommend the form be electronically viewed without a signature requirement.	JPS Health Network	11
23	Virginia Hospital & Healthcare Association -- Jay Andrews	burden; free text field; staff signature; notice content; implementation	The notice cannot be completed in 15 minutes. The free text field is time consuming, subject to interpretation, creates confusion, and is not the intent of the law. This section should be eliminated and reverted back to the original draft or the form could include standard check boxes with common reasons for observation. The notice should contain the CMS logo to make it more official and eliminate questions from patients. Suggest a signature line for a hospital representative or witness. The release of the form should be delayed until manual instructions are completed.	Virginia Hospital and Healthcare	3, 17, 21, 26
24	Northwestern Memorial HealthCare -- Scott Ziomek	state v federal; notice content; guidance; bene signature	For states that have existing laws in place, hospitals should be given the flexibility to use their current procedures as long as they satisfy the spirit of the federal law. Reduce the overall length of the notice to one page. Revise the MOON so that it is in easy-to-understand language. Include in the section entitled "Being an outpatient may affect what you pay in a hospital" a brief statement informing beneficiaries about what is covered under Medicare Part B. Provide guidance on an appropriate definition of observation status. Reduce the length of the section, "Observation services may affect coverage and payment...". Shorten the section entitled " Your cost for medication". Provide guidance for patients who are unable to sign the MOON.	Northwestern Memorial	2, 12, 13
25	America's Essential Hospitals -- Erin O'Malley	reading level; languages; retention policies; bene signature; staff signature; burden	Ensure that the MOON uses terminology that enhances comprehension for all beneficiaries, particularly for those served by essential hospitals. Encourages OMB to require the MOON be made available in various languages. The 15 minute time estimate is insufficient and does not consider all of the administrative time required. Remove the redundancy for retention of the MOON and simply require that hospitals store one copy of the MOON within the patient's medical record, whether it be a hard copy or in the patient's EHR. Further guidance is necessary for fulfilling signature requirement when the representative is contacted via telephone. Include a section for notation of refusal to sign. Encourage OMB to perform analysis of the current notice process and encourage CMS to engage stakeholders in development of an automated process.	America's Essential Hospitals	1, 3, 11, 14, 16, 21
26	Adventist Health System -- Julie Zaiback-Aldinger	free text field; notice content; staff signature	Replace the free text field with a standard explanation that is consistent on all notifications. Revise regulatory text of the MOON to make the notice easier to understand (see comment for additional suggestions for content revisions). Include a witness signature line for hospital staff. Provide sufficient space at the top of pages 1 and 2 for a hospital to affix a standard label.	Adventist Health System	3, 11, 26
27	Louisiana Hospital Association -- Kevin Bridwell	free text field; notice content	Recommend replacing the free text field with check boxes with common reasons for the patient's outpatient status or suggested narratives for insertion in this section. In the third section stating, "Medicare Part A generally doesn’t cover outpatient hospital services...", we believe a repeat of "When you're a hospital outpatient, your observation stay is covered under Medicare Part B" would be beneficial at this point.	Louisiana Hospital Association	11, 26
28	University of Kentucky -- Pam Ryan	notice content; free text field; delivery timeframe; bene signature	The MOON begins with a negative comment “you are NOT inpatient because”. This could easily begin with “you are in outpatient observation because…” . A generic simple statement or check boxes would be much better for the Medicare population rather than individualizing each notice. Patients should be notified a early as possible regarding their observation status versus waiting for the 24-36 hour timeframe. Concerns with notifying a representative in a timely manner if the bene is unable to sign in unique scenarios.	University of Kentucky	2, 9, 11, 26
29	St. Charles Health System -- Lisa Wilson	free text field; notice content	There should be standard language prepopulated in the free text field. The language in the section "Observation services may affect coverage.." may lead to additional pressure placed on the physician by beneficiaries to admit as an inpatient.	St. Charles Health System	11, 26
30	Woman's Hospital -- Emily Stevens	free text field	The free text field should be replaced with CMS-prepared standard language that describes the reason the patient is being placed in observation.	Woman's Hospital	26
31	Baum Harmon Mercy Hospital -- Angue Shilling	delivery timeframe	Would like to see the notice given to Medicare patients upon admission to outpatient status rather than waiting for 24-36 hours	Baum Harmon Mercy Hospital	9
32	Healthcare Association of New York State -- Lynne Williams	free text field; notice content; state v federal; three day SNF requirement	Recommends that CMS provide check boxes with common reasons for the patient's outpatient status. Suggests adding language to clarify that time spent as an outpatient receiving observation services does not count towards the three-day SNF requirement. Consider providing further clarification regarding Part B coverage. CMS should consider allowing states with separate observation laws to use a form comparable to the MOON to reduce maintenance and administrative burden.	Healthcare Assoc. of NY State	12, 13, 26
33	Woman's Hospital -- Rob Hawkins	notice content; bene signature	The statement, “NOTE: Medicare Part A generally doesn’t cover outpatient hospital services, like an observation stay.” will confuse Medicare benes into thinking their stay will not be covered. The statement, , “You can also ask to speak with someone from the hospital’s utilization or discharge planning department.” is not necessary. The current instructions do not include procedures for refusals or inability to sign.	Woman's Hospital (2)	1
34	St. Francis Memorial Hospital -- Kathy Stratman	MA concerns; burden	Is CMS going to inform MA plans of the notice? MA plans are not timely in completing admission reviews. How are we expected to deliver the MOON if the patient is admitted to acute care and later it is determined they should have been placed in observation. The burden placed on hospitals is underestimated. There is no need for another notice and for the Medicare population to sign.	St. Francis Memorial	7, 21
35	Community Hospital Anderson -- Pat Woods	burden	The MOON questions hospitals credibility having to explain reasons for care. Provides opportunity for bene to pressure physician into changing the level of care. Extremely resource intensive. Increases burden on personnel who are already providing and prioritizing time	Community Hospital Anderson	22
36	New Hampshire Hospital Association -- Travis Boucher	free text field; bene signature; burden	Remove the free text field from the MOON and replace with standard language developed by CMS. Add space at the top of each page for label. The section that describes how observation services affect coverage should be made clearer. The current instructions do not explain refusals or inability to sign. The burden is underestimated and an additional 15 minutes should be added for delivery.	New Hampshire Hospital Assoc.	1, 2, 11, 21, 26
37	Health & Disability Advocates -- Emily Gelber-Maturo	plain language; appeal rights; provider education	Use plain language to ensure comprehension. Include a process for challenging the observation status determination. Training is recommended for staff and it is advised that CMS provide technical assistance to hospitals on implementation of physician documentation within the medical record as to why the patient is receiving observation services.	Health & Disability Advocates	5, 11, 23
38	California Hospital Association -- Alyssa Keefe	free text field; implementation; notice content; staff signature; languages	Without revisions the MOON does not meet OMB criteria for approval. Remove the free text field and replace with the previous bullet points in the last version of the MOON. Delay implementation and enforcement. Create additional check boxes to indicate oral notification and when an interpreter is used. Create a signature line for staff when the patient is unable to sign and no representative was available. Provide in additional languages. Change the patient name and id number to be consistent with the IM. Provide additional guidance on implementation of the MOON.	CHA	2, 11, 16, 17, 26
39	Maine Medical Center -- Bailey Holloway	free text field; delivery timeframe	Operationalizing the free text field is a concern due to the variation in staff that will be issuing the notice. Can generic language be added to the free text field? It is recommended to issue the MOON upon admission to observation	Maine Medical Center	9, 26
40	New Jersey Hospital Association -- Theresa Edelstein	free text field; notice content	CMS should work with stakeholders to develop appropriate language for a checklist of reasons for observation to replace the free text field. The last bullet stating "20% of the Medicare-approved amount for most doctor services, after the Part B deductible" should be removed.	New Jersey Hospital Assoc.	11, 26
41	Association of American Medical Colleges -- Ivy Baer	free text field; delivery timeframe	Suggest the title be changed to "Medicare Outpatient Observation Notice: Medicare Rules and Your Possible Financial Obligations". Remove the free text field and replace with standardized language. CMS should clarify that the Agency will rely on the judgment of each provider to determine the best time to deliver the MOON, provided that it is delivered to within the 24 hour and 36 hour timeframe	AAMC	9, 26
42	Beth Israel Deaconess Medical Center -- Hollis Bono	notice content; burden	The MOON should adopt similar to language to what has already been published in other resources. The notice should define what observation is. Revisions should be made to the financial responsibility section. Consider adjusting language in the IM to issue one notice instead of two. Language should be added to indicate that there are no appeal rights. See comment for additional suggestions for content revisions.	BIDMC	11, 21
43	Tennessee Hospital Association -- Tammy Kemp	free text field; burden	Remove the free text field from the notice and replace with standardized language developed by CMS. Underestimated burden. Suggest adding an additional 15 minutes for completion.	Tennessee Hospital Assoc.	21, 26
44	RWJBarnabas Health -- Sarah Lechner	state v federal; delivery timeframe; bene education	Conflicting requirements between state and federal notification are a cause for concern in regards to the timing of delivery. CMS should provide further guidance to hospitals on overlapping federal and state requirements. Request flexibility in the timeframe for delivery. Expand bene education	RWJBarnabas	9, 13, 23
45	Trinity Health -- Tonya Wells	delivery timeframe; free text field; issuance; state v federal; bene signature	Remove the language that discourages providing the MOON at the time of initiation. CMS should work with stakeholders to develop appropriate language for a checklist for the free text field. Does the MOON need to be signed again just to add inpatient admission date and time? How do we handle the IM that will be provided to the patient upon admission? There is concern about the conflict between New Jersey's requirement with respect to the timing of delivery.	Trinity Health	6, 9, 13, 26
46	American Hospital Association -- Roslyne Schulman	free text field; notice content; burden; bene signature	Remove the free text field and replace with standard language developed by CMS. Add space at the top of each page for label. The section that describes how observation services affect coverage should be made clearer. The current instructions do not explain refusals or inability to sign. The burden is underestimated and an additional 15 minutes should be added for delivery. . Keeping the free text field increases the logistical burden.	AHA	1, 2, 11, 21, 26
47	Sentara Halifax Regional Hospital -- Linda Conner	state v federal; secondary insurance; delivery timeframe	Consider state regulation process. It would be easier if the notice was given at the time of placement in observation rather than waiting. CMS rule contradicts Code of Virginia requirements. How would patients be handled that had insurance primary to Medicare.	Sentara Halifax Regional	8, 9, 13
48	North Carolina Hospital Association -- Christie Johnston	free text field; MA concerns; bene education; three day SNF requirement	Consider developing a checklist of acceptable reasons a beneficiary may receive observation services versus inpatient services and include them in the free text field. Exclude MA enrollees. Increase bene education. CMS has the authority to allow the time spent in observation to count towards the 3 day SNF requirement.	North Carolina Hospital Assoc.	5, 7, 23, 26
49	Florida Hospital Association -- Kathy Reep	free text field; implementation; notice content; staff signature	Remove the free text field and replace with the previously added bullet points. If finalized as is, CMS must allow for hospitals to develop standardized text to be used for all patients. Delay implementation and enforcement timeline. Add a signature line for staff to sign the document acknowledging the information was provided but at the time the beneficiary was unable to sign and there was no representative available. Change the patient name and ID number to be consistent with the IM. Provide additional guidance regarding implementation.	Florida Hospital Assoc.	3, 11, 17, 26
50	Greater New York Hospital Association -- Lorraine Ryan	free text field; burden; notice content	The free text field should be eliminated. This should be pre-populated with standardized language explaining the overall intent of observation status. Underestimated burden on hospitals and the time it will take to complete the form. The MOON will cause confusion and anxiety for the patient. Remove the requirements to include hospital and physician names, time, and date from completed form.	Greater New York Hospital Assoc. (1)	21, 26
51	Franciscan St. Margaret Health -- Denise Gard	free text field	CMS should consider adding a statement in the reasoning section and not require hospitals to fill in this field. Leaving this section blank increases the burden on hospitals	Franciscan St. Margaret Health	26
52	Aurora Health Care -- Jackie Wanner	notification; free text field	If the patient is discharged prior to receiving the MOON, does a hospital that provides oral notice of the MOON by telephone, then mails the hard copy satisfy the requirement? Can this also apply to the Power of Attorney or Guardian? Provide standard language for the reason patients are in observation status.	Aurora Health Care	6, 26
53	Marion General Hospital -- Angela Mounsey	free text field	Consider check boxes for observation reasons.	Marion General Hospital	26
54	Allina Health -- Tracey Stanich	free text field; bene signature and date; state v federal requirement	The patient signature and name is not necessary. Remove the free text field. The patient signature and date do not provide CMS with the necessary date collection and useful information. Better align state and federal requirements	Allina Health	11, 13, 26
55	Driscoll Children's Hospital -- Tonya Hunter	dual eligible benes	Recommend an exclusion clause for Pediatric organizations with a dual eligible population. The MOON will cause confusion and stress for families, misunderstanding that they may have to pay out of pocket if they are placed in observation status. The labor and financial burden of implementing the MOON does not provide any benefit to the patient.	Driscoll Children's Hospital	8
56	Methodist Health System -- Cynde McCall	delivery timeframe	We plan to issue the MOON at the time of admission for those patients we anticipate will require 24 hours or greater of observation services. Does this meet compliance?	Methodist Health System	9
57	Genesis Health -- Sherri Brown	delivery timeframe	What are CMS' thoughts on the recommended timeframe of between 24 and 36 hours versus the notice being issued prior to the 24 hour period	Genesis Health	9
58	Advocate Health Care -- Shauna McCarthy	free text field; notice content; staff signature	Use standardized language in the free text field, clearly stating the patient is who receiving observation care is an outpatient not an inpatient, and providing a plain language explanation of why the patient is being treated as an outpatient. Provide sufficient space at the top of pages 1 and 2 for a hospital to affix a standard label. Further streamline the information on page 1 describing how being an outpatient affects what the patient will pay. Include an additional witness signature line for hospital staff	Advocate Health Care	3, 11, 26
59	Inspira Health Network -- Peter Kaprielyan	state v federal; free text field; notice content	The delivery timeframe differs between federal and state requirements which may cause confusion for Medicare benes who are receiving two notices for observation status. Consider check boxes rather than the free text field. CMS should work with stakeholders to develop appropriate language for a checklist of reasons. Remove the bullet: "20% of Medicare-approved amount for most doctor services, after the Part B deductible."	Inspira Health Network	13, 26
60	Illinois Health & Hospital Association -- Susan Melczer	free text field; notice content; burden; staff signature	Replace the open text field with a standard explanation of why the patient is an outpatient. Provide sufficient space at the top of pages 1 and 2 for a hospital to affix a standard label. Further streamline and clarify the MOON. Add a signature line for hospital staff. Consider the full burden of this new information collection effort on Illinois hospitals, which will be establishing workflow processes to meet both state and federal requirements.	Illinois Hospital Assoc.	11, 3, 21, 26
61	Greater New York Hospital Association -- Rosanne Casey	file code	Can you tell me if CMS-10611; OMB control number 0938-New is the file code for MOON?	Greater New York Hospital Assoc. (2)
62	Providence Medical -- Tammie Thomsen	MA concerns	If more than 36 hours after MA member was admitted as inpatient and discharged as inpatient the MA plan denies the inpatient stay and wants to approve as observation/outpatient. How can we bill for meds, etc. when the MOON notice is a requirement and it was never issued?	Providence Medical	7
63	LHP Hospital Group -- Vivian Street	free text field; MA concerns; recipients	Can standard language be added in the reasoning section. MA plans often wait more then 36 hours before a decision is made with regard to placement in inpatient or observation. CMS should omit the requirement to provide to MA patients. The MOON should be given to every patient receiving observation services regardless on the time spent in this status	LHP Hospital Group	6, 7, 26
64	Coulee Medical Center -- Karie Schuler	delivery timeframe	Timeframe is confusing for staff and benes. The patient should receive notification at the time of admission to observation status. Additional staff will be needed to issue the notice, given the timeframe.	Coulee Medical Center	9
65	Eastern Maine Healthcare Systems -- Lisa Harvey-McPherson	free text field; notice content	Remove the narrative section and simply state on the form the patient is receiving notice as a hospital outpatient receiving observation services. Remove language referring to Part A inpatient coverage.	EMHS	11, 26
66	University of Utah Healthcare -- Shaynie Lentz	free text field	Individualized reasoning behind observation status is unreasonable and will lead to increases in Medicare length of stays and increased costs associated with this. Allow the use of generic statements to complete this section of form	University of Utah	26
67	Hamlin Health -- CEO	compliance; burden; bene education	Who will monitor the additional requirement for compliance? Reimbursement for observation stays is very low and will require more time explaining the form. Is CMS going to notify the bene of this change?	Hamlin Health	18, 21, 23
68	Upland Hills Health -- Vicki Scheel	oral explanation requirement	The oral explanation requirement will be extremely time consuming and not easily fit into the fast-paced care process. This will increase administrative burden and costs for hospitals, Medicare support staff and providers. Eliminate the explanation required	Upland Hills Health	20
69	Memorial Medical Center -- Jerry Pickett	notice content; delivery timeframe	Consider rewording "You are not an inpatient because:". This will alarm patients who are not familiar with the difference between observation and inpatient status. Would be better to include an explanation of the difference between observation and inpatient status. The document will cause patients to worry and puts hospitals in an uncomfortable position. Would it be possible to give a document at the end of the observation stay explaining what the implications of their stay were.	Memorial Medical	9, 11, 26
70	Health Services of Coshocton County -- Karen West	delivery timeframe	The MOON should be given before the patient is admitted to observation status so a decision can be made based on the patient's best interest	Health Services of Coshocton County	9
71	Archbold --Hope Cedeno	delivery timeframe	Patients should be notified at the beginning of an observation stay rather than wait for the 24 hour timeframe to begin. Expecting staff to wait until 24 hours after placement is an added burden	Archbold	9
72	Individual Comment -- Melissa Sole	Notice content	Aren’t there rules about the length of time a patient can be kept in observation. Should that be included? Or at least provide a definition of observation from the manual. Consider revising the language for "You're a hospital outpatient…"	Individual Comment - Melissa Sole	11
73	Novant Health Presbyterian Medical Center -- Muhammad Al Mounayer	free text field; notice content	Include language in the reason section regarding the 2 midnight rule rather than leaving it blank for the provider to fill in. Revise language regarding the Part A inpatient services to include "...if the hospital admits you as an inpatient based on meeting the medical and regulatory requirements as determined by your treating physician and Medicare’s guidelines”. Add language regarding MA plans. Clarify that appeal rights do not apply to observation care.	Novant Health	11, 26
74	Glens Falls Hospital -- Irene Grey	free text field	Having to list the specific reason for observation status puts the physician and staff in a bad position. The patient nor their caregiver will likely understand the information being provided	Glens Falls Hospital	26
75	Fulton County Health Center -- Elizabeth Mohr	notice content	Under the section "Observation services may affect coverage and payment of your care after you leave the hospital" the word "3-day" should be changed to "3-midnight"	Fulton County Health Center	11
76	Tallahassee Memorial HealthCare -- Valerie Foster	state v federal; delivery timeframe; free text field	Why are we being asked to notify patients who are in observation but may be changed to inpatient status? This creates more confusion for the patient. State regulation requires notification at the point of discharge for those individuals whose stay was in outpatient observation, which works well for us. What was the purpose of removing the standardized language regarding the reason for observation status	Tallahassee Memorial HealthCare	9, 13, 26
77	Baystate Medical Center -- Rebecca Rondeau	free text field	There should be standardized language on the notice for the reason behind observation status. Hospital staff should not be trying to explain to the patient why the physician ordered observation status.	Baystate Medical Center	26
78	CaroMont Regional Medical Center -- Sharmarke Magan	MA concerns	If more than 36 hours after MA member was admitted as inpatient and discharged as inpatient the MA plan denies the inpatient stay and wants to approve as observation/outpatient, at that point what is the resolution if the MOON is not issued. Will there be an exception to mail the notice or will MA plans be required to make the status determination on the front end?	CaroMont Regional	7
79	Gundersen Health System -- Joan Brueggeman	free text field	Would CMS consider preprinting information related to why the patient is receiving observation services. Specifically, language from the 2 midnight rule. Clerical staff delivering the notice may not know the medical justification behind placement. Standardized language would reduce the burden	Gundersen Health System	26
80	St. John Health System -- Mary Scott	Code 44 notice	Address cases that changed from inpatient to observation with both the Code 44 notice and the MOON being required. The Code 44 process should be discontinued in light of the new regulation	St. John Health System	10
81	McCullough-Hyde Memorial Hospital/TriHealth -- Katrina Dudley	delivery timeframe; free text field	Notification should be permitted before the 24 hour period. The specific reason section appears to be a liability if worded incorrectly. If there is going to be a section for reason, then there should be appropriate choices to choose from. Because the physician is making the determination for observation how can a nurse/care manager be expected to know the reason when issuing the notice 24 hours after the decision was made	McCullough-Hyde Memorial	9, 26
82	Arctic Slope -- Brianne Bucatcat	repercussions; Indian Health Services	What are the repercussions of not handing out the form? Indian Health Services hospitals have no reason to issue this form. Even if Medicare denied the claim, they cannot send the patient a bill by law.	Arctic Slope	18
83	Palo Alto County Health Systems -- Anna Zwiefel	free text field	Reasoning section appears to increase vulnerability for staff to make mistakes leading to liability and legal issues. CMS should provide guidelines for this section. Clerks that will be filling out the form should not be filling out this section and to expect the provider to complete this section prior to signature is unrealistic.	Palo Alto County Health Systems	26
84	Ardent Health Services -- Jennifer King	free text field; patient dissatisfaction	Concern about the information staff will preprint in the reasoning section regarding the 2 midnight rule. The notice will result in patients expecting to be inpatients which will require additional communication and dissatisfaction.	Ardent Health Services	26
85	Hillcrest HealthCare System -- Rikki Moye	free text field	Consider check boxes for the specific reasoning behind observation status. CMS should provide guidelines for specificity of this field.	Hillcrest HealthCare System	26
86	Matagorda Regional Medical Center -- Martha Valdez	free text field	Recommend a signature confirming oral explanation of the reason(s) for observation services rather than the free text field to reduce burden on hospital	Matagorda Regional	26
87	Schuylkill Medical Center -- Andre Grant	state v federal requirement; burden; SNF requirement; bene education	Duplication of state requirements. Underestimated burden. Eliminate 3 day SNF requirement. Bene education	Schuylkill Medical	5, 13, 21, 22, 23
88	TriHealth -- Linda Hogel	burden; free text field; MA concerns	The burden is unrealistic. Consider check boxes for the specific reasoning. This notice should not be delivered to MA enrollees	TriHealth	7, 21, 26
89	CHI Health - St. Mary's -- Donnette Hoyle	free text field	Burden on clinical staff to provide the specific reason for observation status. Consider putting options on the notice	CHI Health	26
90	Odessa Memorial Healthcare Center -- Mo Sheldon	free text field	Remove the specific reasoning or provide clear specific guidelines for decision making	Odessa Memorial	26
91	Oklahoma Heart Hospital -- Mercy Mathew	notice content; burden; free text field	The MOON is going to scare the patient. Medicare patients do not know the difference between inpatient and observation. Increases hospital burden. Shorten the MOON to one page and remove the free text field	Oklahoma Heart Hospital (1)	11, 22, 26
92	McLaren Greater Lansing -- Sandra Palmer	free text field; notice content; delivery timeframe; contact information	It is not appropriate for staff other than the treating physician to specify a reason for observation. Language regarding inpatient services is misleading. Delivery timeframe is difficult to meet. Will patients be able to reach someone during evening, night and weekend hours	McLaren Greater Lansing	9, 11, 26
93	Oklahoma Heart Hospital -- Lori Staley	notice content; free text field	Adds an additional workload, and negates the PRA of 1995. Shorten the form and do not ask for reason(s) for observation as this will add more time to delivery	Oklahoma Heart Hospital (2)	11, 26
94	Wisconsin Department of Health Services -- Deidria Mundy	display of information	Supports the law. Believes there should be signage in rooms where observation takes place, giving the information in brief	Wisconsin Department of Health Services	6, 11
95	Union General Hospital -- Julie Duty	implementation	When is the effective date and when will the final notice be available for use	Union General	17